1639486343 NPI number — CHARLES DREW HEALTH CENTER, INC

Table of content: (NPI 1639486343)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639486343 NPI number — CHARLES DREW HEALTH CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHARLES DREW HEALTH CENTER, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CHARLES DREW HEALTH CENTER, INC AT KING SCIENCE CENTER SBHC
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639486343
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 30019
Provider Second Line Business Mailing Address:
2915 GRANT STREET
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68111-3863
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-451-3553
Provider Business Mailing Address Fax Number:
402-457-1220

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3720 FLORENCE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68110-1737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-502-5644
Provider Business Practice Location Address Fax Number:
402-502-6436
Provider Enumeration Date:
09/02/2010

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
TARSHA
Authorized Official Middle Name:
DENISE
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
402-457-1215

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163WC1500X , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QC1500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QC1500X , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100262314-00 . This is a "NON-FQHC" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 100262310-00 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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